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PubMed1995

Changes in plasma warfarin levels and variations in steady-state prothrombin times.

OBJECTIVE: To determine the relative contribution of changes in the plasma warfarin level to variation in the serial steady-state prothrombin times. METHODS: This was a prospective observational cohort study performed at two outpatient anticoagulation clinics. Serial prothrombin times and paired plasma total warfarin levels were determined in a convenience sample of otherwise healthy patients who required long-term oral anticoagulation therapy with warfarin. RESULTS: Serial measurements were obtained from 129 patients, 60 of whom provided three or more serial samples. Analysis of covariance showed a highly significant (p = 0.0001) relationship between the anticoagulant effect and the logarithm of the warfarin concentration (R2 = 0.75), with 15.3% of the total variance attributable to the effect of warfarin and 31.1% attributable to individual variation in sensitivity to warfarin. In an analysis of the subjects who had three or more serial measurements, the mean weighted correlation coefficient for the relationship between the logarithm of the warfarin concentration and the anticoagulant response varied widely, from strongly negative to strongly positive, and as the range of observed prothrombin times increased, stronger positive correlation was observed. CONCLUSIONS: In this cohort, the plasma warfarin level was a strong predictor of observed changes in serial prothrombin time measurements. However, the correlation between clotting times and warfarin levels varied widely among subjects, particularly when the range of observed prothrombin times was moderate. This suggests that in these subjects, other factors, such as measurement error or pharmacodynamic changes, played a major role.

Adult↗
PubMed1991

An analysis of duplicate testing of prothrombin time and activated partial thromboplastin time assays.

An evaluation of duplicate prothrombin time (PT) and activated partial thromboplastin time (aPTT) assays determined by the MCA 110 coagulation analyzer was undertaken to develop analytical duplicate performance criteria to quantitate the risks associated with single versus duplicate procedures. Included in the study were 1,277 patient samples. On the basis of the currently recommended therapeutic range for prothrombin ratios, a variation of approximately 10% or more between duplicates was considered to be unacceptable. For aPTT assays, the recommended therapeutic range for heparin therapy was usually 1.5 to 2.5 times the baseline value, and variations of up to 25% might be considered acceptable. With these relatively lenient criteria, approximately 2% of PT and 1.3% of aPTT assays had differences between duplicate values that were unacceptable. From this data the authors concluded that the frequency of errors produced by single estimations was too great for satisfactory clinical practice.

Humans↗
PubMed1988

A comparison of seven prothrombin time reagents--development of an evaluation strategy.

The control of p.o. anticoagulant therapy by the use of prothrombin times or ratios is one of the major functions of a clinical coagulation laboratory. European prothrombin reagents tend to be more sensitive to the effects of p.o. anticoagulants than traditional North American rabbit brain thromboplastin reagents. The clinical importance of this in vitro observation has been emphasized by the results of two recent clinical trials which both suggested that the less intense anticoagulation therapy that results from the use of a European-type prothrombin reagent may be safer. To minimize the clinical effects of differences in prothrombin time reagent formulation, a global correction factor has been developed--the international normalized ratio (INR). Despite this advance in international standardization, individual laboratories need a rapid and efficient method to help select the most appropriate prothrombin reagent for the clinical management of their local patient population. This study has examined the response of a variety of commercially available prothrombin time reagents to normal plasmas and those from anticoagulated patients. Using both classical sampling theory and multiple range testing, it was demonstrated that as few as 20 estimations on normal plasmas and 50 on anticoagulated specimens will permit a clinical laboratory to select a suitable prothrombin time reagent for anticoagulant control of their specific local patient population.

Anticoagulants↗
PubMed2002

Commercial variants of the prothrombin time test as a screening test of acquired coagulation factor II, VII, and X deficiencies in dogs.

The aim of this study was to acquire the single factor sensitivity of three commercial variants of the prothrombin time test (PT(Va1)-Thrombotest, PT(Va2)-Normotest, PT(Va3)-Hepato Quick) for canine plasma. For this purpose, 38 samples from animals with coumarin intoxication followed by vitamin K(1) treatment who had a reduced activity of the coagulation factors II, VII, and/or X (experiment 1) as well as 25 plasma samples from animals with moderately reduced activity of the coagulation factors II, V, VII, and/or X caused by a hepatogenic synthesis disorder or disseminated intravascular coagulation (experiment 2), were examined. Measurements for all tests were performed according to the instructions of the manufacturer and also with higher plasma dilution. Furthermore, control measurements were performed with the conventional prothrombin time test (standard test; PT(ST)). The prothrombin time measured with the PT(Va3), which was prolonged in all samples from experiments 1 and 2, especially reflected with high sensitivity the reduced activity of the coagulation factors. The measurements with PT(Va2) and PT(Va1) showed only an insignificantly lower sensitivity (> or =0.88) with a maximum of 1 (experiment 1) and 3 (experiment 2) false negative test results, respectively. Compared to the already high sensitivity, a higher dilution of the sample material did not lead to a significantly higher sensitivity (P>0.05) for any of the tested commercial variants of the prothrombin time assay. While there was no significant difference (P>0.05) between the number of false negative test results in the variants of the prothrombin time assay, in both experiments a significantly higher number of false negative test results was found for the PT(ST) (P<0.001). The results show that, in contrast to the PT(ST), all three tested commercial prothrombin time variants are suitable for the detection of deficiencies of coagulation factors II, VII, and X in canine plasma.

Animals↗
PubMed2003

A critical evaluation of the prothrombin time for monitoring oral anticoagulant therapy.

The Quick prothrombin time is the most common clotting test performed, principally for monitoring oral anticoagulant therapy. The International Normalized Ratio (INR) for comparing patient results from prothrombin time measurements and the International Standardized Index (ISI) for achieving greater consistency of results using different thromboplastins have made it possible to compare the results of vitamin K antagonist drug therapy that was impossible before the introduction of the INR and ISI. However, INR values obtained from the same patient plasma sample using different thromboplastins are significantly different. This is so even when the thromboplastins have nearly the same ISI values. We suggest that investigation of patient-specific differences can provide a means by which the INR discrepancies can be identified and understood and thus lead to better methods for monitoring oral anticoagulant therapy.

Administration, Oral↗
PubMed2003

Prothrombin time prolongation in paracetamol poisoning: a relevant marker of hepatic failure?

The association between paracetamol overdose and prolonged prothrombin time due to hepatic failure is well recognized. However, little is known of the possibility that paracetamol overdose can prolong the prothrombin time without overt hepatic failure. The few data from the literature suggest this is either due to a reduction in the functional levels of the vitamin K-dependent clotting factors by elevated doses of paracetamol, or a consequence of the administration of the antidote N-acetylcystein. The three reported cases provide further evidence that paracetamol overdose can be associated with a prolongation in the prothrombin time without overt hepatic failure. Even though the prothrombin time provides useful prognosis information, decisions regarding the management of these patients should not solely be based on this endpoint to avoid misinterpretation of the accuracy and the severity of liver failure.

Acetaminophen↗
PubMed1994

A simple method for evaluating prothrombin time in severe liver disease.

A measurement of prothrombin time by a new, whole blood capillary system was evaluated for use in severe liver disease, such as fulminant and chronic hepatic failure. The measurement required a single drop of fresh, whole blood and was easily performed at bedside. Results were available within 5 minutes after collection of the blood samples. Good correlation was observed between prothrombin time values determined by the rapid method and those determined with the laboratory method (r = .89). The laboratory method was used as a reference. The whole blood system may be especially helpful in emergency situations, when central laboratory services are not available.

Acute Disease↗
PubMed1986

Is duplicate testing for prothrombin time and activated partial thromboplastin time necessary?

To evaluate the necessity of duplicate testing for prothrombin times (PTs) and activated partial thromboplastin times (APTTs), the range of differences between duplicate sample results was analyzed on a widely used automated photo-optical coagulation instrument. Specimens with coagulation test times ranging from normal to threefold above the reference range were included. Of 1,610 PTs and 1,023 APTTs, approximately 95% of duplicates differed by 0.2 s or less and 2.0 s or less, respectively. Approximately 99% of PTs and APTTs differed by 0.4 s or less and 4.0 s or less, respectively; there were three PT and 16 APTT specimens whose duplicates differed by a greater time interval and also by more than 5% of the mean. Thus, PT and APTT testing on automated instrumentation is very precise, but occasional inaccurate single measurements could lead to errors in diagnosis or therapy.

Blood Coagulation Tests↗
PubMed1997

Influence of plasma volumetric errors on the prothrombin time ratio and International Sensitivity Index.

The International Sensitivity Index (ISI) for prothrombin time systems depends on the thromboplastin manufacturer's recommended method for use. The purpose of the present study was to investigate the influence of small deviations from the recommended sample volume on the prothrombin time ratio and ISI. Four commercial reagents were studied; three with low ISI and one with high ISI. The effects of volumetric errors on the ISI were used to assess the associated effects on the International Normalized Ratio (INR). The effect of 10% volume error on the INR was not greater than 5%. The effects with the three low-ISI reagents were slightly greater than those with the high-ISI reagent. It is recommended that each laboratory should check the volumes of sample and reagent used for the prothrombin time test.

Anticoagulants↗
PubMed1987

Evaluation of the nature of mildly prolonged prothrombin times.

Twenty-one asymptomatic individuals with a mildly prolonged prothrombin time (greater than 2 SD from the prothrombin time of the reference plasma) were found to have a mild isolated factor VII (F VII) defect (mean 38.8 U/dl; SD 13.2). Factor VII antigen levels were also found to be reduced (mean 45.5 U/dl; SD 7.8) in 13 of them. These figures were compared with those of 50 normals and 28 obligatory heterozygotes for F VII deficiency. The phenotypical behaviors in the propositi were found to be equal to those of the F VII congenital deficiency heterozygotes: the discrepant one (VII+) and the nondiscrepant one (VII-/R). Fifteen families of the propositi could also be studied, totalling 55 additional individuals; in 25 of them (ten pedigrees) a mild F VII deficiency was found showing the same phenotypical features of the corresponding propositi. We therefore believe that these individuals with mild F VII deficiency can be considered as heterozygotes for the defect, since the other vitamin K-dependent clotting factors were normal; the defect is transmitted throughout the kindred with the same mode of inheritance as F VII congenital deficiency; and F VII:C and F VII:Ag levels are highly comparable with those of known obligatory heterozygotes for F VII deficiency. On the grounds of a careful statistical analysis we propose a formula which allows a discrimination between the two phenotypes of the heterozygotes for F VII congenital deficiency. In addition it is suggested that sensitive tissue thromboplastins should be used to pick up these mild defects.

Adolescent↗
PubMed1992

The relation of prothrombin times to coronary heart disease risk factors among men aged 31-45 years.

Although levels of coagulation factor VII and fibrinogen are predictive of cardiovascular disease, relatively little data describe hemostatic characteristics in healthy populations. The cross-sectional associations between the prothrombin time, a measure of the activity of the extrinsic and common pathways of coagulation, and traits associated with the risk of cardiovascular disease were therefore examined among 3,604 white and 514 black, male, US Army veterans aged 31-45 years. The prothrombin time measurements, performed in 1985 and 1986, were precise, with an intraclass correlation of 0.98 (202 pairs). Overall, the mean prothrombin time was 12.4 seconds (standard deviation, 0.4 seconds), and 11 percent of the men had a value of less than 12 seconds. Many of the observed associations with the prothrombin time paralleled those that have been reported with clotting factor VII and fibrinogen. The mean prothrombin time was 0.15 seconds shorter among whites than among blacks and was 0.2 seconds shorter among current cigarette smokers than among men who had never smoked. Inverse associations were also seen with relative weight and with levels of total cholesterol and triglycerides (r = -0.09 to -0.16). All associations were statistically significant at the 0.01 level, and the examined characteristics could jointly account for about 12 percent of the variability in prothrombin times. Additional data on characteristics related to coagulation may help elucidate the natural history of cardiovascular disease and aid in the design of clinical trials.

Adult↗
PubMed1976

Clinical usefulness of measuring prothrombin time as a routine admission test.

A questionnaire indicating the presence of a history or physical findings consistent with liver desease or bleeding disorders was completed by house officers on 301 admissions to a Veterans Administration medical service. Each patient had prothrombin time determined on admission. Only two of 107 patients for whom the prothrombin time was measured as a screening test had an abnormal results and one of these was normal when repeated. Of 73 patients with a history of alcoholism but no other pertient case history or physical examination results, only one had an abnormal prothrombin time. Of the remaining 121 patients, who had a pertinent history or physical examination, 41 had an abnormal admission prothrombin time. We conclude that measurement of prothrombin time adds little additional information to that obtained by history and physical examination in screening for liver disease and coagulation defects unless the patient has specific clinical evidence of liver disease, anticoagulation, or other conditions predisposing to bleeding disorders.

Alcoholism↗
PubMed1990

Prothrombin time in first week of life with special reference to vitamin K administration.

Prothrombin time was estimated in 100 neonates (80 full term and 20 preterm). Among the full term infants 50 were healthy and 30 sick. Prothrombin time was altered in neonates with birth hypoxia and prematurity (p less than 0.001). Vitamin K administration to anoxic babies resulted in improvement in prothrombin time after 48-72 hours (p less than 0.001). Four newborns has bleeding, 2 had anoxia and 2 were only in preterms who did not receive vitamin K after birth. It is concluded that vitamin K should be given to all preterms and those with difficult deliveries; term, healthy newborns do not need it.

Humans↗
PubMed1998

Effect of plasma pooling on the International Sensitivity Index of prothrombin time systems.

Guidelines set by the World Health Organization (WHO) state that in order to calibrate a prothrombin time system for International Sensitivity Index (ISI), freshly prepared specimens from 20 normal individuals and 60 patients receiving coumarin are required. These numbers are required to obtain a precise value of the calibration line slope when there is considerable scatter of individual data about the regression line. The scatter can be reduced by pooling individual plasma samples. In the present study, four pooled plasmas were prepared, one from 20 normal individuals and three from three groups of 30 patients receiving treatment with long-term oral anticoagulants. Prothrombin times were determined with four thromboplastins, HepatoQuick (rabbit thromboplastin combined with adsorbed plasma), Recombiplastin (recombinant human thromboplastin), Thromborel-S (human placenta), and Thromboplastin-C Plus (rabbit brain). Calibration line slopes were calculated for the six possible combinations of thromboplastins using the set of all individual plasma samples and the set of four pooled plasmas. In most comparisons, the WHO calibration model was appropriate, i.e. the line calculated for the patients' samples passed through the mean of the normals. The calibration line slopes obtained with the set of four pooled plasmas did not differ by more than 5% from the corresponding slopes calculated with the original individual plasmas. For some combinations of thromboplastins non-linear relations were observed both with the individual plasmas and with the pooled plasmas. We conclude that pooling individual plasmas does not significantly change the calibration relation between prothrombin times determined with the original individual plasmas. Freshly pooled plasmas can be used to determine the ISI of prothrombin time systems with an acceptable degree of precision.

Anticoagulants↗
PubMed2003

Voriconazole potentiates warfarin-induced prothrombin time prolongation.

AIMS: Voriconazole is a novel triazole with broad-spectrum antifungal activity. It is likely that some patients receiving voriconazole may also require treatment with the anticoagulant warfarin. Cytochrome P450 isoenzymes are important in the metabolism of both these drugs. This study investigated the effect of voriconazole on the pharmacodynamics of warfarin by measuring prothrombin time, and also evaluated the safety and tolerability of the coadministered drugs. METHODS: This was a double-blind, placebo-controlled, two-way crossover study in which healthy male subjects received either 300 mg voriconazole or placebo twice daily on days 1-12, plus a single oral dose of 30 mg warfarin on day 7 of each study period. Volunteers were randomized to one of the following treatment sequences: voriconazole + warfarin followed by placebo + warfarin or placebo + warfarin followed by voriconazole + warfarin. There was a washout of at least of 7 days between treatment periods. RESULTS: The mean Cmax, AUCtau and tmax for voriconazole were 3736 ng ml-1, 25 733 ng.h ml-1, and 1.66 h, respectively. Both the mean maximum change from baseline prothrombin time and the mean area under the effect curve (AUEC) for prothrombin time during coadministration with voriconazole (17 s and 3211 s.h, respectively) were statistically significantly greater than the mean values observed during the placebo period (8 s and 2282 s.h ). Prothrombin times were still increased by a mean value of 5.4 s 144 h post warfarin dose following coadministration with voriconazole compared with a mean value of 0.6 s in the placebo treatment period. CONCLUSIONS: Coadministration of voriconazole and warfarin potentiates warfarin-induced prothrombin time prolongation. Regular monitoring of prothrombin time is recommended if these drugs are coadministered, with appropriate adjustment of the dose of warfarin.

Administration, Oral↗
PubMedDate not supplied

Membrane-based, dry-reagent prothrombin time tests.

The authors describe a prototype membrane-based, dry-reagent prothrombin time assay for whole blood. This system uses an asymmetric polysulfone membrane to separate plasma from red blood cells, and works with samples as small as 10 microliters. The membrane contains calcium and thromboplastin, and permits the reactions of the complete extrinsic pathway to occur with minimal distortion from membrane surface interactions. Thrombin generation is monitored optically using a rhodamine-110-based fluorescent thrombin substrate. Fluorescence kinetics are analyzed to produce a prothrombin-time--equivalent parameter that can be converted to an international normalized ratio (INR) value. The system provides results that correlate well with conventional liquid phase prothrombin time assays (R2 = 0.96).

Anticoagulants↗
PubMed2000

Photodynamic treatment of pooled coumarin plasma for external quality assessment of the prothrombin time.

AIMS: To determine the conditions of photodynamic inactivation of vesicular stomatitis virus (VSV) added to pooled coumarin plasma and the effects of the photodynamic treatment on the prothrombin times and international normalised ratio (INR) in a Netherlands national external quality assessment scheme. METHODS: Pooled coumarin plasma samples were illuminated with visible light in the presence of 1 microM methylene blue. Inactivation conditions for VSV in pooled coumarin plasma were determined using an end point dilution assay. Plasma illuminated for 20 minutes was mixed with red blood cells and mailed to participants of the Netherlands external quality assessment (EQA) scheme. Prothrombin times and INRs were determined with various thromboplastin reagents. RESULTS: Photodynamic treatment using 1 microM methylene blue and 700 W/m2 caused 4.7 log inactivation of VSV in pooled coumarin plasma. Fibrinogen and coagulation factors II, V, VII, and X were decreased slightly by the treatment. These conditions caused prolongation of the prothrombin time in EQA surveys. The magnitude of the effect was different for various thromboplastin reagents. The increase of the INR was negligible when measured with the Thrombotest reagent. With other reagents, an approximately 5-16% increase of the INR was observed. Interlaboratory variation of the INR was not affected by photodynamic treatment. CONCLUSIONS: Photodynamic treatment of pooled coumarin plasma is very effective for the inactivation of some enveloped viruses such as VSV, but has only a limited effect on the prothrombin time and INR. Photodynamic treatment can be used to improve the viral safety of coumarin plasma for EQA of the prothrombin time and INR.

Coumarins↗
PubMed1995

Multicenter evaluation of a new capillary blood prothrombin time monitoring system.

The analytical performance of the new capillary blood prothrombin time monitoring system CoaguChek was examined in a multicenter evaluation at six hospitals. The coefficients of variation of the INR obtained in the CoaguChek imprecision study were approximately 7% in the control plasma provided (within-run and day-to-day) and 4% in blood (within-run). The prothrombin times were ascertained in capillary blood (CoaguChek PT Test) and citrated venous plasma (Hepato Quick, Thromborel S) from 359 patients under oral anticoagulation therapy with phenprocoumon, acenocoumarin or warfarin. The agreement with the test results obtained with the comparison methods was acceptable versus Hepato Quick assay (n = 359; y = 1.23 x -0.49, r = 0.888) and good versus Thromborel S method (n = 359; y = 1.09 x -0.28, r = 0.895). A simplified assessment of all test results (n = 795) in a nine-field comparison table showed a concordance with the comparison methods of more than 80 (Hepato Quick: 81%, Thromborel S: 83%). The concordance between Hepato-Quick and Thromborel S was slightly higher (88%). Its good analytical performance and convenient handling recommend the CoaguChek system as a suitable system for decentralized prothrombin time testing.

Blood Chemical Analysis↗